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DECLARATION OF DOMICILE
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To the Clerk of ~the Circuit Caurt [County Comptroller) ST. LUC 1 E County, Florida.
This is my declaration of domicfle in the State of ~ k'Q11~ , that I am filinq
this day in accordance and in conformity with Section ., Florida Statutes.
FOR DOMICILIARIES OF TH~ STATE OF FL4RIDA:
I hereby declare that I reside in and maintain a place of abode at/loT/o~3 /`~ i ~~fiL~.
~~5~ ~~~ (street an n er)
, in ST. ~ UCIE County, Florida, which place of abode I
(c~ty)
recoqnize and intend to maintain as my permanent home and, if I maintain another place or
places of abode in some other state or states, I hereby declare that my above-described
residence and abode in the State of Florida constitutes my predominant and principal home,
and I intend to continue it permanently as such. I am, at the time of making this declaza-
tion, a bona fide resident of the State of Florida residing at if~7~o~3 /L~~u~~~~n ,
~~5~~~ ~~`~ ~ (street and number)
, in ~~'~,uG~F County, Florida. I formerly resided at
(city) ~i
Ao.s r-o•/ , cS~~ i'Fa~C K County, ~1T~9`ss ~ and the
(city) (state) ~
place or places where I maintain another or other place or places of abode are as follows:
(Here list street•address, city, county and state of any other place or places of abade.)
I BECAME A RESiOENT ON THE /~~ DAY OF ~Ay-'~~~1 ~ 19 7~~ .
~ w w-TT e,n C~, O 1' T~ ~~ ~' ~~ e V~
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• ~tsignature) ~
(mNr~w2.c~' w~?T.~nc~or~,
Sworn to and subscribed before me this a~ day af
Notary Public State of Florida at Large.
My Commission expires .
~,.,~,~ , A. D. 19 P' ~.
ROGER POI ~42AS, CLERK C IRCUI T COURT
ST. LUC i E COUNTY, FLOR I Op
B Y ~q~~,~,~,~ty- OE P U T Y C L E R K
FOR DOMICILIARIES OF STATES OTHER THAN THE STATE OF FLORIDA:
~I~e~iy dec are t at my omacile is in the State of and that I intend
to permanently continue and maintain my domicile in sucri state. At the time of making this
declaration I am a bona fide resident of the State of . Ny place of
abode within the State of Florida, if any, is as follows: (Here list street address, city,
and county of place of abode in Florida.)
(Person making declaration may also include such other and further facts With reference to
any acts done or performed by such person which such person desires or intends not to be
construed as evidencing any intention to establish his domicile within the State of Florida.)
51~9f;1
1981 F~-; 24 ~?; ?: 21
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(siqnature)
Sworn to and subscribed before me this
'JOtary Public State of Florida at Large.
'~y Commission expires .
day of
, A. D. 19 .
a~349 ~~~~ 7~2
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